It is notable that despite other differences, the professionals participating in these FGDs presented a common picture of communication problems related to RT, i.e. a lack of systems and processes for information transfer, unclear role differentiation, a sense of mutual disrespect, and ad hoc communication taking place ‘on the fly’. While all professional groups recognize extensive communication problems, none acknowledge the potential negative effects on patient safety or care which are described in the FGD with patient representatives. Potential hazards described in the FGDs include not reporting medical errors and silently ignoring or actively opposing new guidelines and regulations. While these data are generated from a limited number of focus groups in a specific RT context, we argue that many of the findings and their implications may well be relevant in other—especially high-tech and multi-professional—acute care nursing settings.
Through analysis of these FGDs, we indirectly gain insight into both the safety climate and the safety culture on the RT unit, although this was not the original aim of the project. Sexton et al1 differentiate between the terms safety culture and safety climate, although pointing out that the terms are frequently used interchangeably in health care. They define safety climate as “the consensus of shared perceptions regarding patient safety, and norms and behaviors by frontline workers in a given clinical area” (p 935). Safety culture on the other hand, according to Sexton et al , demands deeper investigation, through “careful and time consuming observation of norms, beliefs, values, artifacts, symbols, and rituals” (p 934). Safety climate may thus change relatively quickly over time to reflect new routines and interventions, for example after a medical error . Safety culture, however, is more deeply embedded and less susceptible to fluctuation or change, as it represents unwritten, rather than formalized rules and regulations. In this study, the FGD participants’ descriptions suggest that both safety climate and safety culture are negatively affected by the above-noted communication deficits.
It should be recognized that this FGD study does not use approaches which according to Sexton et al  would be optimal to in-depth investigate the symbols, rituals and values intrinsic to safety culture. FGDs on the other hand, do generate data about shared perceptions which illuminate safety climate and shed some light on norms and beliefs common to a workplace. There are some factors to consider when interpreting these data however. One is the extent to which existing clinical and workplace hierarchies can be mirrored in some FGDs, with less input from the person further down on a perceived hierarchy. While this was not noted between the RNs and assistant nurses in the FGDs, it may have had more impact in the FGD with other professionals, with the informal leadership role of one participant apparent.
Using evolutionary psychology, Braithwaite et al  present conceptual underpinnings of communication breakdown in health care situations, including their potential negative impact on patient care. They summarize the problem saying “when organizational failure looms, trust and communication are compromised” (p 354), arguing that effective communication and trust between professional groups are essential for a well-functioning multidisciplinary team. Braithwaite et al  mean that managers in health care settings rarely succeed in uncovering existing underlying issues and when they do, that poor communication and lack of trust results in the managers often being ignored by staff, which tends to protect their own interests before that of patients. From another perspective, in their analysis of major health care ‘failures’ from six countries, Walshe and Shortell  summarize common themes as related to 1) longstanding problems which are 2) well-known but not addressed and 3) which can cause immense harm. These often occur in 4) dysfunctional organizations, lacking basic management systems or with systems that are readily bypassed, with a lack of coherent clinical leadership, and with 5) some types of failures occurring repeatedly, thus indicating that “lessons are not being learned” (p 106).
In these FGDs, we both see evidence of the lack of trust pointed to by Braithwaite et al  and the five points highlighted by Walshe and Shortell . RT RNs describe a basic mistrust of physicists, and a situation in which they feel that their professional competence is not trusted by other professionals. Accusations of professional territoriality are raised by different actors, often in relation to RNs, although this specificity may be an artifact of the study focus and design. Many, but not all managers are described as ineffectual and removed from a position allowing real insight into the more subtle problems and needs of the RT units and teams. There is shared recognition of problems, but they are longstanding and have not been adequately addressed, with formal efforts at change often bypassed by staff. The implications for these problems on patient safety, appears to be a lesson that has not been learned, to use Walshe and Shortell’s  expression.
Neither Braithwaite et al  nor Walshe and Shortell  directly broach the topic of hierarchies in health care systems, although this has permeated our FGD data both directly and indirectly. As previously noted, RNs tended to initially deny the presence of a hierarchy between professional groups, although they used language which indirectly indicated that these RNs placed themselves below physicians and above physicists (particularly on one site) in conceptualizations of their workplace, hierarchical roles, and responsibilities. This hierarchical relationship between RNs (primarily women) to physicians (mixed sexes) seems to be generally acknowledged (see e.g. classic work of Stein , further discussed in Stein et al ; Reeves et al ) and tacitly accepted by these RNs—particularly noteworthy in these Swedish data, from a country otherwise renowned for being relatively egalitarian. It can also be noted that little friction was described between the engineers and the RNs by either group, although engineers are generally seen to have higher status and have markedly higher incomes despite the same length and academic status in their educational programs, and the relatively high status (informal and in terms of salary) enjoyed by the RT RNs in comparison with other groups of their peers (e.g. compared to other RN specialists in high-tech environments).
Perhaps the most disconcerting feature of the hierarchical RT environment was the passive role described and assumed by the RT RNs participating in these FGDs in many situations. The RNs often express a lack of “voice” and a sense of powerlessness, but at the same time rarely describe an individual sense of professional responsibility. This pattern was described by Widmark et al  over a decade ago, in regard to another relatively autonomous group of RNs that is midwives in Sweden.
It is important to consider how to constructively impact this situation with the problems and communication deficits noted in these FGDs. Recently, Buljac-Samardzic et al  identified and reviewed three categories of interventions to improve team effectiveness; training, tools and organizational interventions, although the level of evidence was noted to be generally low. Different types of team training were best documented, although the heterogeneity in studies precludes strong conclusions and the researchers end with a call for better fit between diagnosed problems and the interventions to address them, with more attention paid to context. Butterworth et al2 discuss capacity-building and capability in patient safety from a nursing perspective, using an example from England for inspiration. They discuss how RNs are ‘culture carriers’ and how their potential can be maximized through changes in nursing education, increased focus on RNs’ ways of working, and increased interest from research funders. Unfortunately, Butterworth et al  limit their discussion to albeit important, but very specific nursing issues, with little acknowledgement of the role RNs play in organizational settings with multi-professional interaction and the demands this places on communication.